Becker's Hospital Review

14 Executive Briefing Optum is a leading health services and innovation company dedicated to helping make the health system work better for everyone. With more than 85,000 people collaborating worldwide, Optum combines technology, data and expertise to improve the delivery, quality and efficiency of health care. "Screening tools cannot capture all the nuances of any particular patient's stay in the hospital, whereas a physician advisor is better suited to do that," he says. Moreover, physician advisors can review cases that fail screening criteria to make recommendations tailored to the patient based on regulatory expertise, involvement of the treating physician and evidence- based medicine. 2. Staff satisfaction increases with better communication. Physician advisors are invaluable to utilization review staff and case managers. "Case managers like having physician advisors around," Dr. Hopfensperger says. "They are a backup; they're a support; they're a resource." 3. Metrics may improve. "One hallmark of an effective program is improved accuracy of outpatient/observation rates and inpatient rates," Dr. Hopfensperger says. Hospitals can also expect to see more timely utilization reviews, a reduced denial rate and more successful claim appeals. In many instances, physician advisors can serve as the lead on utilization review committees, identifying gaps in the process, comparing progress against benchmarks and providing course correction as needed. 4. Physician advisor programs can boost revenue integrity. Physician advisors can help hospitals improve compliance and adjust to appropriate reimbursement rates, ultimately optimizing operational efficiency. "A physician advisor helps get your revenue as close as possible to where it should be from a utilization review standpoint," Dr. Hopfensperger says. Obstacles for adoption of a physician advisor program While most hospitals could benefit from a physician advisor program, several challenges thwart adoption. One of the biggest challenges is gaining administrative support. Launching the program is often seen as a cost rather than a resource to better manage revenue integrity and possibly a revenue generator. "One of the unusual things is that many hospitals don't link revenue and cost during their budgeting process," says Dr. Hopfensperger. "And many times a physician advisor will provide multiples of revenue compared to the cost of the program." On top of initial costs, administrators' support is necessary long- term. Physician advisors are not a temporary fix for utilization review challenges. Dr. Hopfensperger likens physician advisor programs to blood pressure medications. "You take your medicine and your blood pressure goes down. You don't then say, 'Well now I don't need my medicine anymore.'" "It's also important to demonstrate the longevity of the role when recruiting candidates. Few physicians are likely to make a career change unless they know the field has a long-term outlook," Dr. Hopfensperger says. In addition to finding a physician who is in it for the long haul, it is important to find the right person for the job. An ideal physician advisor is willing to continuously digest new information on regulations and risk, which may also potentially be outside of their clinical purview. They must be excellent communicators because the role requires tough conversations with clinical staff about poor documentation or other medical necessity issues. This means a hospital may have to make an external hire to ensure objectivity. "Internally sourced physician advisors may be reluctant to have difficult conversations because of their friendships and relationships. They may, if they are still practicing, rely on referrals from their fellow physicians — hospital politics weigh heavily in the situation," Dr. Hopfensperger says. In addition, hospitals need to fully equip advisors with the necessary resources — including time. This means hospitals should provide formal training in clinical risk, access to journals across a wide range of medical specialties, and time for physician advisors to fully research cases and document the clinical facts supporting their recommendations. Lastly, hospitals must also provide a mechanism for feedback. "A physician advisor can research a clinical situation for risk very thoroughly, but if that physician advisor lacks knowledge and experience of what the administrative law judges require under Medicare, or what is being allowed ultimately by commercial insurers after appeals are exhausted, it turns into an academic exercise than a realistic opinion for what makes someone an inpatient," says Dr. Hopfensperger. Getting started with a physician advisor program With those considerations in mind, hospitals ready to initiate a physician advisor program in their organizations can begin by surveying existing physician advisor programs and services. "You've got everything from the homegrown, do-it-yourself, internally sourced physician advisor to third-party services that provide remote physician advisors who are available by email or telephone," Dr. Hopfensperger says. He advises administrators to talk to their peers, look at the available literature and sample the websites of physician advisor companies. When they find a fit for their organization, selecting the right physician to champion the program will help gain buy-in among staff. Successful programs are led by physician advisors who are willing to join in grand rounds and department meetings and catch up with physicians in the lounge or hallway to discuss decisions. The results physician advisors are able to achieve in improving outpatient-inpatient ratios, lengths of stay and even patient mortality quality reporting will demonstrate their value to hospital leadership. Education helps achieve buy-in among staff, while results drive approval from administrators, according to Dr. Hopfensperger. "If the physician advisor is effective, he or she will do both of those well." n

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